Payment Detail: Enhanced Medical Home Payments for Advanced Medical Homes Serving Members Eligible for Tailored Care Management

This bulletin replaces the Nov. 16, 2022, bulletin.

NOTE: This bulletin replaces the Nov. 16, 2022, bulletin Enhanced Medical Home Payments for Advanced Medical Homes Serving Members Eligible for Tailored Care Management

This bulletin includes administrative payment details and timelines for enhanced $20 per member per month (PMPM) medical home payments for beneficiaries eligible for Tailored Care Management (TCM) beginning Dec. 1, 2022, through June 30, 2023.

The additional payment, paid on top of the current base PMPM fee payment of $2.50 or $5.00, to total to the $20 enhanced medical home payment level (referred herein as the “incremental PMPM payment"), will be made through a separate payment stream. 

NC Medicaid will base the payments on the monthly enrollment used for the current Aged, Blind and Disabled (ABD) and non-ABD PMPM management fee payments to calculate the incremental PMPM payment needed. 

  • Effective Dec. 1, 2022, through March 30, 2023, NC Medicaid will deliver an incremental PMPM payment to AMH tier 1, 2, 3, locations for each TCM beneficiary assigned to the AMH. The incremental PMPM payment will be equal to the total Enhanced Medical Home $20 PMPM less the TCM beneficiary’s $5.00 ABD or $2.50 non-ABD monthly medical home payment. 
  • Effective April 1, 2023, through June 30, 2023, NC Medicaid will deliver an incremental PMPM payment to AMH tier 1, 2, 3 locations for each NC Medicaid Direct TCM beneficiary assigned to the AMH. The incremental PMPM payment amounts will be equal to the total Enhanced Medical Home $20 PMPM less the TCM beneficiary’s $5.00 ABD or $2.50 non-ABD monthly medical home payment.
  • Effective April 1, 2023, through June 30, 2023, AMH tier 1, 2, 3 locations with Tailored Plan TCM beneficiaries assigned to the AMH will receive the $20 enhanced medical home PMPM payment from their contracted Tailored Plan. 

Payments administrated by NC Medicaid will be made to primary care providers (PCPs) through monthly claims payments in a single EFT transaction. PCPs should leverage the AMH NC Medicaid Direct/Managed Care PCP Enrollee Report along with the NC Medicaid EFT remittance statement to distribute the Enhanced Medical Home payments to their respective AMH tier 1, 2, 3 locations. Continuation of the payment after June 30, 2023, depends on funding availability and may be tied to additional performance expectations for primary care engagement. 

NC Medicaid Payment Details

For incremental PMPM payments made by NC Medicaid: AMH tier 1, 2, 3 locations assigned as the PCP for NC Medicaid beneficiaries eligible for TCM will receive the PMPM difference between the current $5.00 ABD and $2.50 Non-ABD management fee payments to reach the $20 PMPM enhanced medical home payment. The table below shows a breakdown of the enhanced payment amounts that will be made regardless of beneficiary ABD status:

TCM Beneficiary ABD Status Current ABD/Non-ABD PMPM Incremental PMPM Payment 12/1/22-6/30/23 Total Enhanced Medical Home PMPM 12/1/22-6/30/23
ABD $5.00  $15.00  $20.00 
Non-ABD $2.50  $17.50  $20.00 

NC Medicaid will calculate the $15.00 (ABD) and $17.50 (Non-ABD) PMPMs to reach the intended $20 PMPM per assigned TCM beneficiary. The table below shows an example of these calculations and the resulting monthly payment:

ABD Status Total Monthly Beneficiary Count Incremental PMPM Payment Total Monthly Enhanced Medical Home Payment
ABD 2 $15.00  $30.00 
Non-ABD 4 $17.50  $70.00 
Total Financial Transaction 6   $100.00

NC Medicaid Payment Distribution

PCPs will receive the incremental PMPM payments made by NC Medicaid through monthly management fee checkwrites. The payments will be combined with regular claims payments in a single EFT transaction. PCPs can identify the total amount of incremental PMPM payment funds through a remittance message on the FINANCIAL TRANSACTION page of the Remittance Statement. For example: 

DRAFT Remittance Statement: "TCM-MEDICAL HOME: SEE DETAIL IN ENHANCED MEDICAL HOME BULLETIN PUBLISHED 12-X-22"

Provider Payment Distribution and Reconciliation

PCPs should use the applicable month’s AMH NC Medicaid Direct/Managed Care PCP Enrollee Report along with the NC Medicaid EFT remittance statement amount to calculate and distribute the $20 PMPM to their respective AMH tier 1, 2, 3 locations. 

As of Dec. 4, 2022, the assigned TCM entity’s business name and location is included in the PCP’s AMH Medicaid Direct/Managed Care PCP Enrollee Report.

Payment Timelines

Due to pending system development, NC Medicaid will release expected checkwrite dates in a subsequent bulletin.

Resources

Contact

Medicaid.DCW.HelpDesk@dhhs.nc.gov

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